Determinan Kejadian Pending Klaim BPJS Rawat Inap di Rumah Sakit Daerah dr. Soebandi Jember

Alamanda, Widha (2022) Determinan Kejadian Pending Klaim BPJS Rawat Inap di Rumah Sakit Daerah dr. Soebandi Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

National Health Insurance (JKN) program is a compulsory social health insurance for all Indonesian residents. JKN claims were billed monthly by hospitals to obtain reimbursement for services that have been provided to BPJS Kesehatan participants. Pending claims occured due to claims that have been submitted still receiving confirmation from BPJS Kesehatan. The number of pending inpatient claims at RSD dr. Soebandi Jember in the final quarter of 2021 was found to be 219 claims (12.55%) from a total of 1745 files. This study aimed to analyze the determinants of of pending inpatient BPJS claims based on Gibson's performance variables. This type of research is qualitative with data collection techniques of observation, documentation, interviews, USG and brainstorming. The results of the research on the determinants of pending inpatient claims on individual variables were due to the mismatch abilities and skills of coding officers and DPJP, the implementation of internal verification has not been maximized, and there were differences in perceptions regarding claim regulations between coders and BPJS verifiers; organizational variables due to incomplete claim requirements, errors in internet networks, software and hardware, the implementation of an evaluation of pending causes that has not been carried out regularly causing an impact on RSD dr. Soebandi Jember such as the increased workload of officers, the disbursement of claim funds is not timely and interfere hospital operations; and psychological variables due to there was no provision of rewards and punishments. Efforts to fix the problem are the need for person in charge of the completeness of the quantity of medical record filling in each inpatient room, the application of a one stop administration system, increasing the understanding and accuracy of coding officers, communicating with BPJS to equalize perceptions of claim regulations, and making SOP for claim installation downtime.

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